What happens if the House GOP health bill actually passes? Then it gets really ugly.

Now that the Republican health-care bill has passed the House, there's a whole other set of obstacles it faces in the Senate. (Jenny Starrs/The Washington Post)

Republicans are engaged in a frantic effort to assemble enough votes in the House for the latest version of the American Health Care Act, their bill to repeal the Affordable Care Act. After so many pratfalls and so much public disgust with what they’re attempting, can they actually pull this off?

It’s possible. So it’s worth running through the various scenarios to see how things might proceed from here, if they do.

Just to catch us up, after the first version of the AHCA failed because it was opposed by both moderate Republicans and the ultra-right Freedom Caucus, lawmakers tried to make the bill more cruel, in the hopes that the extreme conservatives would find it pleasing enough to vote for. One of the changes they came up with was to allow states to essentially gut the ACA’s provision requiring insurance companies to cover people with preexisting conditions. Depending on what you include, that’s somewhere between one quarter and one half of all non-elderly Americans.

The preexisting conditions question is quickly becoming the axis around which this debate is revolving, which is understandable, given the large portion of the population whose fates are at stake. Republicans insist that their bill actually protects all those tens of millions of Americans, but make no mistake: if you’re one of them and this bill passes, your life will become hugely more complicated, potentially more costly and possibly in danger if you’re unlucky.

Today, Republicans seem to be picking up a few more votes here and there because of the most recent change to the bill, the addition of $8 billion over five years for high-risk pools into which those with preexisting conditions would be shunted. This is a laughably small amount of money compared with what would be required to insure this population, but it may be enough for vulnerable Republicans to believe they can evade the public’s fury over what they’re trying to do. So what happens from here? Let’s run through the possibilities:

This version of the AHCA dies in the House. While many Republican House members haven’t said where they stand, the number of explicit GOP “No” votes has been hovering around 20 in the past couple of days, with many others leaning against it or undecided; if they lose 23, the bill fails. I think this is the most likely scenario, but that’s just a gut feeling. The politics of this debate are just dreadful for Republican members, who are already terrified that 2018 will be a “wave” election that sweeps them out of office, and they’re acutely aware of the anger that has built up against their bill and how broadly unpopular it is. That may provide enough of an incentive for those last few to bail on it, especially if it looks as though it can’t succeed. There’s no great political outcome on offer, but it’s better to vote against something that failed than to vote for it. At least then you can claim you had something better in mind.

They pass a bill in the House, which then dies in the Senate. Although Republicans are trying to push this latest bill through the House before the Congressional Budget Office gives it a score, this is in many ways the same bill that the CBO said would result in 24 million Americans losing their health coverage. If it loses a mere three Republican votes in the Senate (where they have a 52-48 advantage), it’s over. In some ways, this is the best political scenario for Democrats: The ACA remains intact, but they get to savage GOP members of the House for voting for something so dreadful.

The bill passes in the House, gets radically changed by the Senate, and then fails when it comes back to the House. Members of the House leadership have been trying to persuade moderate Republicans to vote for this bill on the basis that once the Senate gets a hold of it, their version will be less horrifying, and then the two houses could pass something more like what the Senate produces. Which is possible — but the problem is that if the Senate moderates the bill, it could lose the support of the Freedom Caucus members who are now supporting the current version precisely because of the widespread suffering it would cause. “They better not change it one iota,” said Freedom Caucus member David Brat, visions of millions of people being kicked off Medicaid no doubt dancing in his eyes. “If they change it, you’re not going to have 218 [votes].” It’s impossible to know how many votes such a bill would lose in the House until we know what it contains, but the general presumption has been that nothing conservative enough to pass the House could pass the Senate, and nothing liberal enough to pass the Senate could pass the House.

The bill passes in the House, the Senate passes a version, then the two houses work out a compromise in the conference committee that majorities of both houses can support. This is the ultimate path to victory, but it depends on a lot. Among other things, Republicans in the Senate would have to craft a bill that meets the requirements of “reconciliation,” which mandates that only provisions with a direct effect on the budget are allowed. Otherwise, the bill would be subject to a filibuster, and be doomed. That means certain provisions that are policy changes without direct budgetary effects — such as allowing insurers in one state to sell plans in the other 49 states, something most Republicans want — couldn’t be included. They could pass some reconciliation-ready provisions without undoing the whole ACA, such as undoing its expansion of Medicaid or slashing the subsidies people now get to help afford insurance. But it’s clear that they’d rather rip the bandage off all at once.

What this all comes down to is a political calculation every Republican member of the Senate and House is going to make. On one side is keeping the promise they made to their base to repeal the ACA. On the other side is the political danger any version of the AHCA will present to them.

And that danger is almost incalculably high. While the details of the bill may change, we know for certain that it will be spectacularly unpopular. There’s just no way around that. It will boot tens of millions off their insurance. It will endanger coverage for tens of millions more. And while there will be some winners — mostly young, healthy, well-off people who will wind up paying less for their insurance — their numbers will be dwarfed by the losers. When people have to once again go through the onerous process of documenting every pill they’ve taken and ache they’ve had checked out when they apply for coverage — which you don’t have to do now, but you will if Republicans get their way — they’re going to be seriously ticked off.

As Republicans push out new revisions to save their health-care plan, The Post's Paige W. Cunningham explains the sticking points spurring on the internal fighting over the bill. (Jenny Starrs/The Washington Post)

The news media will be filled with horror stories of people who lost their coverage, and in some cases their lives, because of what Republicans did. If the bill passes, it will result in an outpouring of rage, particularly on the left but among all kinds of voters, that will vastly increase the chances of a Democratic wave in 2018 and even 2020.

Republicans certainly want to pass something, if only to show that they kept their promise and they can get things done. But if that something looks as though it could mean the end of their careers, don’t be surprised if enough of them shake their heads and step back from the precipice at some point or other during this process. They will have many opportunities to pull the plug.

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